Provider Demographics
NPI:1033965355
Name:JACKSON, MATTHEW (PD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 E LAKE ST # 332
Mailing Address - Street 2:
Mailing Address - City:MANILA
Mailing Address - State:AR
Mailing Address - Zip Code:72442-9196
Mailing Address - Country:US
Mailing Address - Phone:870-623-2280
Mailing Address - Fax:
Practice Address - Street 1:301 E LAKE ST # 332
Practice Address - Street 2:
Practice Address - City:MANILA
Practice Address - State:AR
Practice Address - Zip Code:72442-9196
Practice Address - Country:US
Practice Address - Phone:870-623-2280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-26
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD08340183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist